| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,395 |
1,395 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
1,617 |
1,617 |
$44K |
| D0274 |
Bitewings - four radiographic images |
974 |
974 |
$26K |
| D1120 |
Prophylaxis - child |
552 |
552 |
$22K |
| D0330 |
Panoramic radiographic image |
615 |
615 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
515 |
515 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
180 |
130 |
$9K |
| D1206 |
Topical application of fluoride varnish |
162 |
162 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
263 |
263 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
26 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
56 |
$578.20 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$393.00 |
| D9110 |
|
14 |
14 |
$358.15 |
| D1330 |
|
1,168 |
1,168 |
$0.00 |
| D0603 |
|
842 |
841 |
$0.00 |
| D0601 |
|
163 |
163 |
$0.00 |
| D1310 |
|
446 |
446 |
$0.00 |